ABC’s of Nephrology Sobha Malla RD,CSR 9/17/11 Renal Diet ABC’s of Nephrology Sobha Malla RD,CSR 9/17/11

Objectives Nursing staff will understand the basic premise of a renal diet Understand the nutritional needs Hemo and Peritoneal Dialysis patients

CHRONIC KIDNEY DISEASE One in nine Americans has Chronic Kidney Disease. Early detection can help prevent the progression of kidney disease to kidney failure. High risk groups for CKD include those with diabetes, hypertension and family history of kidney disease. Groups with increased risk include African Americans, Hispanics, Pacific Islanders, Native Americans and the elderly.

CHRONIC RENAL FAILURE Progressive and irreversible loss of function that occurs over many months or years Causes include diabetes, hypertension and glomerular diseases Some form of renal replacement therapy is needed for life

STAGES OF CHRONIC KIDNEY DISEASE GFR (mL/min/1.73m2) EFFECT ON HOMEOSTASIS 1 ≥ 90 Minimal; excretory and secretory functions intact. 2 60 - 89 Usually no symptoms, but may have high BP, anemia & disturbance in Ca+ & Phos+ metabolism. 3 30 - 59 May have fatigue, anemia, swelling, high BP &/or Ca+ & Phos+ disturbance. 4 15 - 29 Usually symptomatic. Prepare for renal replacement therapy. 5 < 15 Unable to maintain homeostasis without dialysis or transplant.

Goals of the Patient Specific Renal Diet Improve/preserve nutritional status Optimize functional status Maintain patient safety Prepare for transplant Compensate/adjust diet for illness, catabolic events It is important to adequately assess patients that are risk for PEM. Liberalized diet may be necessary for malnourished patients. Preparing for transplant: If BMI>40, suggest wt.loss, better phos control.

Subjective Global Assessment Recognized by KDOQI as a useful measure of PEM Provides a nutritional score based on 2 components Medical history: history of wt. loss (6 months), eating habits, GI symptoms, physiological functions and metabolic stress Physical assessment: visual assessment of loss of subcutaneous fat and muscle mass Patient is scored on a 7–point scale (1) 6-7 well nourished 3,4,5 mild to moderately nourished 1 or 2 severely malnourished

Renal diet for Dialysis patients consists of individualized modifications Calories Protein Sodium Potassium Phosphorus Calcium Fluid Carbohydrates Fat/Cholesterol

KDOQI recommends NHANES II Data CALORIES Adults on Hemo Dialysis and Peritoneal Dialysis < 60 years old 30-35Kcals / Kg SBW > 60 years old or obese 30 Kcals / Kg SBW KDOQI recommends NHANES II Data for assessing SBW

Protein 1.2 grams of protein per Kg SBW for Hemo Dialysis 1.2 - 1.3 grams of protein per Kg SBW with for PD

Protein Important for growth and maintenance of body tissue Provides energy and fights infection Keep fluid balance in the blood 2 types of Protein High Biological Value (HBV) or animal protein-meat, fish, poultry, eggs, tofu, soy milk, and dairy Low Biological Value (LBV) or plant protein – breads, gains, vegetables, dried beans and peas and fruits

Protein The following list contains foods and their protein content: ▪ 1 egg=7 g protein ▪ 1-2 ounce (oz) chicken thigh=14 g protein ▪ 8 oz skim milk=8 g protein ▪ 1 slice of bread=2 g protein ▪ 1 cup (C) cooked rice=4 g protein ▪ ½ C corn=2 g protein

Phosphorus A mineral found in almost all foods. Normal kidneys will balance the amount of phosphorus in our bodies. When the kidneys fail the phosphorus increases in the blood. It is necessary to limit and/or avoid high-phosphorus foods. Control of phosphorus is often difficult for kidney failure patients. Dietary goal is 1-1.5gms/day Normal range <5.5 Hemo clears 500-1000mg per treatment, mainly during the first 60-90minutes of HD.Because hyperphosphatemia alone was linked to increased morbidity and mortality, dietary phos control and binder compliance is very important.

Phosphorus Foods high in phosphorus include: Dairy products Dried beans and peas Nuts Peanut butter Bran cereals Whole wheat bread Meats Food Additives

Potassium Dietary Goal is usually 2 - 3 gms/day Potassium is a mineral , plays a role in regulating your heartbeat; so, too much can result in heart problems. Explore with patient high or low serum potassium levels Monitor residual renal function, changes in appetite for dietary adjustments A stricter K+ allowance may be indicated if the pt has insulin deficiency, metabolic acidosis, is treated with beta blockers or is in a hypercatabolic state.

Low Potassium foods Apples Grapes Berries Pineapple Tangerine Cabbage Green Beans Cauliflower Eggplant

Potassium Common high K+ foods include many fruits and vegetables: Prunes and Prune juice Orange and Orange juice Bananas Dried fruits Potatoes Tomatoes Brussels sprouts Spinach Beets Milk

Sodium HD 2-4 gm/d PD usually more liberal Too much sodium in the blood is related to high blood pressure and congestive heart failure. Foods high in sodium include: Processed meats Canned soups Salty snack foods Deli meats

Sodium 1 Tsp salt = 2000mg sodium Most of us eat 3,000-6,000mg of sodium /day Low sodium = ≤140mg/serving Do not buy a food that has 150-350mg sodium/serving

Fluids Hemo Dialysis: Fluid individualized to accommodate fluid gains, blood pressure control, residual renal function. Peritoneal Dialysis: Fluid individualized to patient tolerance. Strive for minimal use of hypertonic solution to maintain fluid balance. Everything that is liquid at room temperature 1500ml-2000ml ~6 c-8 c /day 4 cups=32 oz=1 qt=1000ml=1 liter Fluid balance in PD is maintained by varying the dextrose concentrations of the dialysate. If pt is unable to maintain fluid balance, fluid and sodium may be restricted.

Fluids Choices include all drinks and foods that are liquid at room temperature. Water Coffee Tea Sodas Soups Juices Jell-O

Fluids Cont.. Thirst Quenching Ideas : Suck on sour candies or chew gum Eat chilled fruit, frozen grapes and berries Add lemon or Lime juice to water Take pills with apple sauce instead of liquids Use smaller cups or glasses Keep track of all liquids Limit salty foods If diabetic, control blood sugars

CALCIUM Hemo Dialysis Patients Balance is determined by: Dietary Calcium Intake Calcium Supplements and Calcium Based Binders Dialysate Calcium Levels Vitamin D Therapy Physician Monitoring of PTH Dietary intake of calcium is frequently decreased to ~500mg per day, due to the limitation of high phos dairy foods in the HD diet. Current recommendation for PD patients is 2000mg per day, with no more than 1500mg from calcium based phos binders. Vit D supresses PTH production and enhances calcium absorption in the gut.

PD - HYPERGLYCEMIA / WEIGHT GAIN CARBOHYDRATE Carbohydrate intake may need to be modified for Patients with Diabetes to achieve the goal of HgAIC < 7 % CAUTION ! HYPOGLYCEMIA PD - HYPERGLYCEMIA / WEIGHT GAIN

FAT / CHOLESTEROL Cardiovascular Disease is the most frequent cause of death among patients with Renal Disease regardless of treatment modality. Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile and individualized treatment goals Consider nutritional status / protein, energy deficits Mortality from CVD in HD and PD patients is ~9% per year, which is about 30 times the risk in the general population. Am J Kidney Dis 1998 HD patients generally have normal LDL, Low HDL and High TG PD patients have higher Total Cholesterol and LDL, and elvated TG due to continuous absorption of glucose from the dialysate. Encourage fiber intake.

Supplements Multi Vitamins Vitamin C Water soluble Vitamin C Supplementation may improve Iron availability from stores Limit to 60-100mg/d to avoid oxalate formation Iron and Zinc supplementation must be determined individually based on labs

Monitoring Monthly QAPI report to review the labs and discuss plan of action to correct the problem Monthly interdisciplinary Care plan meeting to review the patient performance Albumin to monitor intake (Goal >3.5mg/dl) Potassium to determine dietary restriction (Goal 3.5-5.5mg/dl) Phosphorus to adjust binders & compliance (Goal <5.5 mg/dl)

Summary When a patient has a diagnosis of renal failure, their nutritional needs are complex—Levels of Protein, Calories, Fluid, Sodium, Potassium, Calcium Phosphors need to be regularly monitored and make changes based on pt’s needs. It is important to continuously monitor their labs , PO intake , provide or offer nutritional supplements, encourage dietary and medication compliance

Question and Answers Which food is highest in Potassium? Apple Pineapple Broccoli Banana Potato

Q & A Correct answer… Apple -1 medium(62 mg) Pineapple -1/2c(150mg) Broccoli -1/2c(127mg) Banana -medium(451mg) Potato- medium (926 mg)

Q & A What are the foods high in Phosphorus? Pizza (Cheese and meat) Chicken American Cheese Yogurt Cream Cheese Cottage Cheese Oatmeal

Q &A Pizza (1-1/8 slice -131mg Po4, 1780mg K+, 382mg Na) Chicken (1oz-60mg po4) American Cheese (1oz- 211 mg Po4, 46 mg K+, 405 mg Na) Yogurt (fruit 6 oz - 150 mg Po4, 310 mg K+, 100 mg Na) Cream Cheese (1tbsp- 15 mg PO4, 17mg K+, 43 mg Na) Cottage Cheese (4 oz- 152 mg Po4, 97 mg K+, 459 mg Na) Oatmeal (instant, 1 cup - 176 mg PO4, 131 mg K+, 377 mg Na)

Q &A Why do dialysis patients need to limit dairy and high phosphorus foods?

Q &A Healthy kidneys get rid of Phosphorus from the body, but when kidneys fail, phosphorus builds in the blood. High levels cause calcium to come out of the bones and make them brittle, weak and painful. It also gets deposited in soft tissues like blood vessels and heart, causing damage to them.

Q &A How does the diet for someone on peritoneal dialysis differ from the one for hemodialysis? A. It requires more calories B. It requires more calcium C. It requires less protein D. None of the above

Q &A A. It requires more calories B. It requires more calcium C. It requires less protein D. None of the above

Q &A If you are on a renal diet, you most need to limit your intake of what three things?  a. Apples, oranges, grapes. b. Carrot cake, ice cream, Coke. c. Sodium, phosphorus, potassium d. Seafood, surf-and-turf Red Lobster entrees, macaroni and cheese.

Q &A a. Apples, oranges, grapes. b. Carrot cake, ice cream, Coke. c. Sodium, phosphorus, potassium d. Seafood, surf-and-turf Red Lobster entrees, macaroni and cheese.

References 1) A Clinical Guide to Nutrition Care in Kidney Disease American Dietetic Association, 2004 2) Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease, 4 th Edition, National Kidney Foundation, 2009 3) Core Curriculum for Nephrology Nursing, Fifth Edition. American Nephrology Nurses Association, 2008.

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